Transition to Community Referral
Transition to Community Referral Form
Nursing Facility is responsible for obtaining agreement and permission from each individual resident, through the usual signed release of information, in order to send that individual’s name to the DAAS Program Manager for referral to the appropriate MAC Center.
DAAS Program Manager is responsible for reviewing and sending the TCR form to appropriate MAC Center. The Program Manager will maintain a Transition to Community referral tracking system with the MAC Center.
MAC Center is responsible for determining program referral and/or community support services. The center will also provide educational packets and training regarding community resources to nursing facilities, agencies, and organizations to help facilitate the process.
The Referral Agency will contact the individual or the responsible party with information about services and/or resources in the community.
The nursing facility will complete the TCR form and send it to the DAAS Program Manager within 10 business days of a “yes” response to item Q0500B of the MDS 3.0.
The TCR form should be completed and submitted to the DAAS Program Manager by email to MACCenterTCR@mdhs.ms.gov.
If there is a breach in the secure email, TCR referrals should be sent to the DAAS Program manager via fax at 601-359-9664. The nursing facility should notify the DAAS Program Manager of the intent to fax the referral by sending an email notice that does not contain Protected Health Information (PHI) to MACCenterTCR@mdhs.ms.gov.
The DAAS Program Manager will have one business day to review the TCR form, enter data into the Transition to Community referral tracking system, and forward the referral to the appropriate MAC Center via email.
The MAC Center will make a determination of program referral and/or community support services within 2 business days of receiving the TCR form. The date of receipt of the referral will be recorded and starts the timed process. The MAC Center will contact the Referral Agency to provide information regarding the individual and services and/or support needed for the individual’s transition to community.
The Referral agency will contact the individual or responsible party within five business days of receiving referral from the MAC Center. The Referral Agency will provide the individual or responsible party with information about services and/or resources in the community. Nursing facility residents who qualify for waiver services should be given priority or placed at the top of the waiting list when there are no current resources (slots) available if: (a) their nursing facility stay is greater than 90 days, and (b) Medicaid has paid for at least one day of the nursing facility stay. Referrals that do not meet the previously stated criteria should be contacted within five business days and placed on the referral waiting list. The TCR form should be returned to the appropriate MAC Center Manager with Disposition Determination by the 16th business day after receipt of the referral. If there is no determination by the 16th day from receipt of the referral, the MAC Center must receive a notification of progress.
The MAC Center Manager will communicate Disposition Determination to the DAAS Program manager by the 16th business day after receipt of the referral.
The DAAS Program Manager will enter the Disposition Determination into the Transition to Community referral tracking system.